Introduction.
A retrospective case control study of all rehabilitated patients who suffered amputations of the lower extremity by sepsis was performed in the HELIOS centre of rehabilitation for amputees, Bad Berleburg, Germany. This study examines patients who had undertaken an amputation of the lower extremity caused by severe sepsis and septic shock. Methods: Case control study. The clinical reports of 448 patients with amputations of the lower extremity clinically rehabilitated from 2010 to 2013 were systematically and statistically evaluated. Sepsis is classified in 4 categories: SIRS, sepsis, severe sepsis and septic shock. Epidemiology: The mean age of the amputees was 61.33 years, with 25 men and 11 women. Marital status: 16 patients are married (44.44%), 7 divorced, 5 widowed, 7 unmarried, 1 unknown. 24 patients are retired (66.67%). School-leaving qualifications: 22 elementary school (61.11%), 8 secondary school, 1 high school, 5 unknown. Health insurance: AOK 10 patients (27.77%), BEK 7 patients (19.44%), pension insurance 9 patients (25.0%). The medial time of hospitalization in the clinic for rehabilitation of the amputated patients suffering sepsis was 27.23 days. Results: 36 patients, – 8.03 % of all – with 39 amputations, suffered a loss of the lower extremity caused by severe sepsis and septic shock: 1 patient suffered an exarticulation of both hips, 20 patients suffered a transfemoral amputation (1 patient had a transfemoral amputation of both legs), 17 patients lost their leg by transtibial amputation (1 patient had a transtibial amputation of both legs). 13 patients presented a sepsis by MRSA (multiresistant Staph. aureus 36.11%), 8 patients with MSSA (multisensible Staph. aureus), 4 patients with multiresistant Acinetobacter (8.33%), 2 patients with MRSE (multiresistant Staph. epidermidis), 13 patients with other multiresistant germs (36.11%) such as Streptococcus B, Enterococcus faecalis, Enterobacteriaceae, Klebsiella. Mobility class of amputees at the beginning of hospitalization: class 0 (= non walkers) all 36 patients (100%). Mobility class of amputees at the end of hospitalization: class 0 (= non walkers) are 5 patients (27.78%), class 1 (= only inside walkers) are 5 patients (13.89%), class 2 (= inside and little outside walkers) are 18 patients (50.00%), class 3 (= inside and good outside walkers) are 3 patients (8.33%).
Purpose:. Despite advances in limb reconstruction, there are still a number of young patients who require trans-tibial amputation.
Purpose. We aim to determine the amputation rate and identify predictors of outcome in patients with tibial fractures and associated popliteal artery injuries at a level 1 trauma unit draining a large geographical region. Material and methods. All patients with popliteal artery injuries and tibial fractures treated at a level 1 trauma unit between 1999 and 2010 were assessed retrospectively regarding amputation rates and prognostic factors and tested for significance with a Z-test of proportions. Results. Thirty consecutive patients were reviewed with a mean age of 30.5 years and a male preponderance of 73.3%. Motor vehicle accidents (MVAs) and gunshot wounds (GSWs) constituted the mechanism of injury in 17 patients (56.7%) and 11 patients (36.7%) respectively. Twenty-one cases were polytrauma patients. Intra and extra-articular metaphyseal fractures (AO 41 A-C) were seen in 19 patients and diaphyseal fractures (42 A-C) in 7 patients. Primary amputation was performed in 7 patients and delayed amputation in 10 patients giving an overall amputation rate of 56.7%.
Tibiotalocalcaneal arthrodesis (TTCA) is a salvage procedure to functionally block the ankle and subtalar joints to treat severe ankle and hindfoot disease. Complication rates range between 20-40%, with below-knee amputation rate 1.5-19%. The heterogeneous patient cohort and indication(s) for surgery make post-operative outcomes difficult to predict. Consulting patients about potential pain and functional outcomes is difficult. When researching this area commonly, PROM data is used, less frequently functional objective measures like the 2-minute-walk-test (2MWT) are used. The aim was to compare the PROMs and objective outcomes between patients who underwent TTCA and BKA. Fifty-two patients underwent a TTCA using an intramedullary hindfoot nail. Indications for TTCA, post-traumatic OA, failed arthrodesis and malalignment. These patients were compared to 11 patients who underwent unilateral below knee amputation (BKA) due to trauma. Outcomes measures PROMs AOFAS ankle hindfoot scale and Shor-Form 36 (SF-36). Objective measures; 2MWT, Timed-up-and-go (TUG). Mean age TTCA 55.9, BKA 46.4. Average follow-up time 53 months. TTCA group had average 6.3 operations prior to arthrodesis (range 1-23). Of the TTCA group two ankles did not unite (7%), all complication rate 35%, 18% reported no pain. A significant negative correlation was demonstrated between the clinical outcome and the number of surgeries prior to the TTCA. TUG and 2MWT had significantly (p<0.05) better outcomes for the BKA group compared to TTCA. SF-36 BKA patients scored higher than the TTCA patients on physical functioning (p<0.01) and mental health (p<0.05) subscales as well as the mental component score (p<0.05). This study gives clinicians evidence about the natural history of hindfoot arthrodesis and functional outcomes from BKA. Hopefully this study will improve evidence to help patients and surgeons make decisions about expected surgical outcomes from TTCA and BKA procedures.
Chronic osteomyelitis (COM) of the lower limb in adults can be surgically managed by either limb reconstruction or amputation. This scoping review aims to map the outcomes used in studies surgically managing COM in order to aid future development of a core outcome set. A total of 11 databases were searched. A subset of studies published between 1 October 2020 and 1 January 2011 from a larger review mapping research on limb reconstruction and limb amputation for the management of lower limb COM were eligible. All outcomes were extracted and recorded verbatim. Outcomes were grouped and categorized as per the revised Williamson and Clarke taxonomy.Aims
Methods
Knee arthrodesis (KA) and above knee amputation (AKA) have been used for salvage of failed total knee arthroplasty (TKA) in the setting of periprosthetic joint infection (PJI). The factors that lead to a failed fusion and progression to AKA are not well understood. The purpose of our study was to determine factors associated with failure of a staged fusion for PJI and predictive of progression to AKA. We retrospectively reviewed a single-surgeon series of failed TKA for PJI treated with two-stage KA between 2000 and 2016 with minimum 2-year follow-up. Patient demographics, comorbidities, surgical history, tissue compromise, and radiographic data were recorded. Outcomes were additional surgery, delayed union, Visual Analog Pain scale (VAS) and Western Ontario and McMaster Activity score (WOMAC). No power analysis was performed for this retrospective study. Medians are reported as data were not normally distributed.Aim
Method
Observing a decreasing number of transfemoral amputations following infection of Total Knee Arthroplasty (TKA) we performed a retrospective case control study of all rehabilitated amputees in the HELIOS centre of rehabilitation for amputees, located in Bad Berleburg, Germany. This study examines all patients who had undertaken a transfemoral amputation (TF) after infection of TKA since 2007. Methods: retrospective case control study. The clinical reports of 355 patients with transfemoral amputation rehabilitated from 2007 to 2013 were systematically and statistically evaluated. In this period we rehabilitate 636 amputees. Results: 9 patients – 2.53% of all TF-amputations suffered a loss of the lower extremity caused by an infection of TKA. 3 patients presented an infection only by MRSA (multiresistant Staph. aureus 33.33%), 2 patients only with MSSA (multisensible Staph. aureus); other 4 patients presented mixed infections with MRSE (multiresistant Staph. epidermidis), multiresistant Acinetobacter baumannii, E. coli, Enterococcus faecalis, Pseudomonas aeroguinosa. Epidemiology: The mean age of the patients at time of amputation was 70.07 years, with 4 men and 5 women. Marital status: 6 patients are married (66.66%), 1 divorced, 1 widowed, 1 unmarried. All patients are retired. School-leaving qualifications: 7 elementary school (60.87%), 1 secondary school, 1 unknown. Health insurance: AOK 3 patients (33.33%), BKK 3 patients (33.33%), employers insurance 1 patients (11.11%) and 2 more patients. The medial time of hospitalization in the clinic for rehabilitation after suffering amputation because of infection of TKA was 29.22 days. Mobility class of amputees at the beginning of hospitalization: class 0 (= non walkers) all 9 patients (100%). Mobility class of amputees at the end of hospitalization: class 0 (= non walkers) are 2 patients (22.22%), class 1 (= walking only inside) are 5 patients (55.55%), class 2 (= walking inside and a little outside) are 2 patients (22.22%), class 3 (= walking well inside and outside) no patient. This retrospective case control study shows for the first time that amputation of the lower extremity following infection in TKA is rare – in our group we found 2.53%. In the national and international literature one does not find much research about transfemoral amputations caused by infection in TKA. In our clinic we notice a decreasing number.
Severe military pelvic trauma has a high mortality rate with previous work identifying an association between pelvic fracture and traumatic amputation (TA) of the lower limb (LL). Research has also identified casualties with this combination of injuries as the potential ‘future unexpected survivors’, however, most casualties die early from exsanguination, often before medical interventions can be performed. Therefore targeting injury prevention or mitigation might be the route to increased survivorship. This study investigates this combination of injury and identifies targets for preventative techniques. A search of the JTTR from 2003 to 2014 identified all patients with TA and all pelvic fractures. Of 989 casualties with LL TAs, 19% had an associated pelvic fracture, and this was associated with a 56% mortality rate compared to 24% without. Both pubic symphysis and sacroiliac separation alike were associated positively with traumatic amputation (p < 0.01). The combination of pelvic instability and TA had a mortality rate of 52%. We hypothesise that pelvic fracture may share a mechanistic link with TA, meaning fracture may occur as a consequence of the force and direction of the TA, and it may be possible to direct mitigation strategies at this injury in order to improve survival rates.
An interesting case with excellent accompanying images, highlighting the significance of tourniquets in controlling exsanguination, whilst also raising the issue of amputation versus reconstruction in severely injured limbs. A 39 year old male motorcyclist was BIBA to the Midland Regional Hospital in Tullamore, following a head-on collision with a bus at high velocity. On arrival, he was assessed via ATLS guidelines; A- intubated, B- respiratory rate 32, C - heart rate 140bpm, blood-pressure 55/15 and D- GCS 7/15. Injuries included partial traumatic amputation of the right lower limb with clearly visible posterior femoral condyles, a heavily comminuted distal tibial fracture and almost complete avulsion of the skin and fat at the popliteal fossa. Obvious massive blood loss at the scene had been tempered by a passer-by who applied a beach towel as a makeshift tourniquet. CT Brain demonstrated extra-dural and subarachnoid haemorrhages with gross midline shift. Unfortunately, the neurosurgical team in Beaumont concluded that surgical intervention would be inappropriate. However, his kidneys had not sustained ATN and were made available for donation. Two vital surgical issues were featured in this case. Firstly, it highlighted the importance of tourniquets in controlling exsanguination in a trauma situation1. Secondly, it raised the critical issue of amputation versus reconstruction in severely injured limbs2,3. Without prompt placement of a make-shift tourniquet by a passer-by, this patient would have almost certainly died at the scene of the accident. Two kidneys were successfully donated as a result. The importance of appropriate tourniquet use cannot be overstated. This case highlights its potential life or limb-saving capabilities in emergency trauma situations. It also raises the critical issue of amputation versus reconstruction in acute emergency situations.
Noting a decreasing number of transfemoral amputations following infection of Total Knee Arthroplasty (TKA) I studied a case of a patient which suffered an amputation following infection of TKA by MRSA. With assistance of all hospitals and the NHS it was able to classify all costs of this poor case. This study exposes a drama of a person which received a Total Knee Arthroplasty in the right knee at 66.0 years. 2 weeks after the implantation of TKA she presented a wound secretion, the microbiology shows: MRSA, Pseudomonas aeroguinos and Streptococcus. 4 surgical revisions followed without removing the TKA. 35 month later, with 68.9 years it was indispensable to remove the TKA in a 6th operation, implanting a spacer with Vancomycine. 1 month later removing of the spacer and implanting a second cemented TKA in the 7th surgery. With 70.2 years the removal of the second TKA was necessary because of infection with Pseudomonas aeroguinosa and Morganelli morganii. Now implantation of another spacer with Vancomycine. 1 month later with 70.3 years removal of the spacer molding an arthrodesis of the knee using an intramedullary femur to tibia rod. After that 4 revision surgeries with changing the intramedullary rod some wound revisions followed, ending in the 23rd operation with a transfemoral amputation with 71.1 years – 5 years after primary TKA. 3 month after transfemoral amputation the patient presented high temperature and a secretion of the scarf of the TT-stump; microbiology: MRSA. 2 more surgeries are necessary to stop the infection. This patient suffered over all 25 surgical procedures in 5.5 years. The hospitalization for acute infection of TKA led to 431 days in different hospitals in 33 months. Statement of charges from the hospitals € 74.046,92 in the last three years before amputation. Payments by the health insurance € 155.424,00 for all procedures. We will demonstrate the different costs of hospital procedures and distribution for the insurance for all performances.
UK personnel have been deployed in Afghanistan since 2001 and over this time a wealth of experience in contemporary war surgery has been developed. Of particular note in the latter Herrick operations the injury pattern suffered by personnel is largely blast wounds, primarily from improvised explosive devices. With the development of improved body armour, previously unsurvivable blasts now result in a large number of traumatic amputations, predominantly affecting the lower limb. Faced with this, deployed medical personnel in the Role 3 facility, Camp Bastion, have developed, by a process of evolution, a standard process for timely management of these injuries. We present a documented schema and photographic record of the ‘Bastion’ process of management of traumatic amputation through the resuscitation department, radiology, theatres and post-operatively. In resuscitation the priority is control of catastrophic haemorrhage with exchange of CAT tourniquets to Pneumatic tourniquets. While undergoing a CT, time can be used to complete documentation. In theatre a process of social debridement & wash then sterile prep followed by formal debridement allows rapid management of the amputated limbs. This work provides a record of current best practice that generates maximum efficiency of personnel and time developed over a large number of procedures. This allows reflection both now in relation to continuing Herrick operations and when military medical services are faced with a future conflict and an inevitable change in injury patterns.
Problems associated with soft tissues of the stump and attachment of prosthetic devices for amputees remains a considerable problem. These problems are associated with the transmission of load through the soft tissues of the stump and difficulty in attaching the prosthetic device. Several devices have an osteointegrated transcutaneous prosthesis attached to the residual bone onto which an exo-prostheses is secured thereby transmitting load directly through the skeleton. Infection of these devices is a key issue. A biomimetic intraosseous transcutaneous device for amputees known as ITAP has been developed which is based on deer antler morphology. We have shown that in deer antlers the dermal and epithelial tissues are tethered by collagen fibres which originate from pores in the bone. In a caprine model where the soft tissue interface of ITAP is porous, dermal and epithelial integration occurs creating a seal and preventing infection. In two clinical veterinary cases an ITAP implant has been successfully used in trans-radial canine amputees. A human trans-humeral amputee who previously could not wear their exo-prosthesis has been treated with ITAP. The surgery was single stage procedure and involved the insertion of an uncemented intramedullary stem into the residual humerus. A porous flange structure positioned adjacent to the dermal tissue which had most of the hypodermis removed was used to promote soft tissue ingrowth. At two years' post-operation the skin seal has been maintained, there has been no incidence of infection, the patient wears their exo-prostheses for over 8 hours a day and has an almost complete range of shoulder motion. The use of ITAP device in selected cases may revolutionise the way amputees are surgically treated, lead to increased activity levels and more normal life styles in these patients.
Prosthetic joint infections (PJI) after failed knee arthroplasty, especially in complicated courses with persisting or recurrent infections, may result in a considerable destruction of bone substance, the extensor apparatus and the surrounding soft tissue. In these cases reconstruction of a proper knee function may be impossible and the only solutions are: knee arthrodesis or above-the-knee amputation (AKA). However, both methods are associated with considerable functional deficits and high complication rates. The primary aim of the current study is to analyse the clinical course, outcome and complications in patients with knee arthrodesis and AKA after PJI and to compare these two methods in terms of the analysed parameters. Patients treated with a knee arthrodesis or AKA after PJI in an 11-year time period were included in this study. Demographic data, comorbidities, infecting characteristics and operative procedures were recorded. Patients were seen in regular intervals and underwent physical and radiographic examination. Major complications such as: re-infection, implant-failure, revision surgeries or stump healing disorders were recorded. Functional outcome with use of the Lower-Extremity-Functional-Score was assessed and the patients reported general health status (SF-12-questionnaire) was recorded.Aim
Method
We present the British Military's experience of treating devastating lower limb injuries in personnel returning from Iraq and Afghanistan. We evaluate current surgical practice of attempting to maximise stump length through sequential debridement, rather that early amputation outside the zone of injury. Following an observation that the frequency of sequential amputation had appeared to increase during spring 2009, it was speculated that there may be factors which would predict which patients would require a more aggressive early amputation. The Joint Theatre Trauma Registry was interrogated for all cases of amputation between April 2006 and September 2009. The following data were collected: demographics, mechanism of injury, requirement for massive transfusion, use of combat applied tourniquet, number of stump debridements and echelon of care performed, all microbiology and final level of amputation. A regression analysis was performed to establish correlation between each data-set and final level of amputation.Introduction
Methods
The UK Military Trauma Registry was searched for all cases of primary bilateral lower limb amputation sustained over 6-years between March 2004 and March 2010. There were 1694 UK military patients injured or killed during this six-year study period. Forty-three of these (2.8%) were casualties with bilateral lower limb amputations. All were men injured in Afghanistan by Improvised Explosive Devices. Six casualties were in vehicles when they were injured with the remaining 37 (80%) patrolling on foot. The mean New Injury Severity Score was 48.2 (SD 13.2). Nine patients also lost an upper limb (triple amputation); no patients survived loss of all four limbs. Six patients (14%) sustained an open pelvic fracture. Perineal/genital injury was a feature in 19 (44%) patients, ranging from unilateral orchidectomy to loss of genitalia and permanent requirement for colostomy and urostomy. The mean requirement for blood products was 66 units (SD=41.7). The minimum transfusion requirement was 8 units and the greatest was a patient requiring a total of 193 units of blood products. Our findings detail the severe nature of these injuries together with the massive surgical and resuscitative efforts required to firstly keep patients alive and secondly reconstruct and prepare them for rehabilitation.
To compare the costs of treatment and income received for treating patients with tibial osteomyelitis, comparing limb salvage with amputation. We derived direct hospital costs of care for ten consecutive patients treated with limb salvage procedures and five consecutive patients who underwent amputation, for tibial osteomyelitis. We recorded all factors which affect the cost of treatment. Financial data from the Patient-Level Information and Costing System (PLICS) allowed calculation of hospital costs and income received from payment under the UK National Tariff. Hospital payment is based on primary diagnosis, operation code, length of stay, patient co-morbidities and supplements for custom implants or external fixators. Our primary outcome measure was net income/loss for each in-patient episode. The mean age of patients undergoing limb salvage was 55 years (range 34–83 years) whereas for amputation this was 61 years (range 51–83 years). Both groups were similar in Cierny and Mader Staging, requirement for soft-tissue reconstruction, anaesthetic technique, diagnostics, drug administration and antibiotic therapy. In the limb salvage group, there were two infected non-unions requiring Ilizarov method and five free flaps. Mean hospital stay was 15 days (10–27). Mean direct cost of care was €16,718 and mean income was €9,105, resulting in an average net loss of €7,613 per patient. Patients undergoing segmental resection with Ilizarov bifocal reconstruction and those with the longest length of stay generated the greatest net loss. In the amputation group, there were 3 above knee and 2 below knee amputations for failed previous treatment of osteomyelitis or infected non-union. Mean hospital stay was 13 days (8–17). Mean direct cost of care was €18,441 and mean income was €15,707, resulting in an average net loss of €2,734 per patient. Length of stay was directly proportional to net loss. The UK National Tariff structure does not provide sufficient funding for treatment of osteomyelitis of the tibia by either reconstruction or amputation. Average income for a patient admitted for limb salvage is €6,602 less than that for amputation even though the surgery is frequently more technically demanding (often requiring complex bone reconstruction and free tissue transfer) and the length of hospital stay is longer. Although both are significantly loss-making, the net loss for limb salvage is more than double that for amputation. This makes treatment of tibial osteomyelitis in the UK National Health Service unsustainable in the long term.
We reviewed 78 femoral and tibial non-unions treated between January 1992 and December 2003. Of these, we classified 41 as complex non-unions, because of infection (22), bone loss or prior failed surgery to produce union. These were treated with Ilizarov frames. 39 of the 41 nonunions healed successfully at a median time of 11 months. Using the ASAMI scoring system, we had 17 excellent, 14 good, 4 fair and 6 poor bone results. The functional results were excellent in 14, good in 14, fair in 2 and poor in 2. All but 2 patients were extremely satisfied with the results. The average cost of treatment to the treating hospital was approximately £30,000 per patient. In comparison the cost for a patient with a below-knee amputation was £999 per year. This would amount to a cost of £36,000 per patient in their lifetime. There is therefore not a great difference between the cost of limb salvage and amputation. The difference that exists favours limb salvage, if patient selection can accurately predict the salvage of a useful limb. Early referral to tertiary centres would reduce the morbidity and the prolonged time off work. The results justify the expense but the NHS needs to make financial provision for reconstruction of complex nonunions.
Advances in the management of open tibial fractures have reduced the incidence of long-term complications of these injuries. However, a number of patients continue to suffer from sequelae such as infection, non-union and malunion. Many orthopaedic surgeons believe a below-knee amputation with a well-fitted prosthesis is a better alternative to limb reconstruction surgery. There are few studies that evaluate the long-term functional outcomes of amputees against patients who have undergone limb salvage procedures, and their results are conflicting. The hypothesis of this study is that patients who have undergone limb salvage have as good or better outcomes than those who have had below-knee amputations. This is a retrospective case study. One group (n=12) had been treated with below-knee amputation following a variety of lower limb fractures. The other group (n=11) had developed complications following tibial fractures and undergone limb salvage surgery using the Ilizarov method. The groups were compared by means of a postal questionnaire, comprising the Oswestry Disability Index and the SF-36 Health Survey.Introduction
Methods
Traumatic amputations (TAs) are amongst the most significant orthopaedic sequelae following IED strikes. Biomechanically, longer residual limb length confers better function. However, post-trauma definitive through knee amputation (TKA) remains controversial. UK military casualties sustaining ≥1 major TA, 01/08/2008–01/08/2010 were identified using the UK JTTR and post mortem CT databases. All through- and below-knee TAs were termed ‘potential TKAs’ (p-TKAs); hypothetical candidates for definitive TKA. We hypothesised that traumatic TKAs were more common than previously reported (4.5% of lower limb TAs) and a significant cohort of blast injuries exist suitable for definitive TKA. 146 cases (75 survivors, 71 fatalities) sustained 271 TAs (235 lower limb). TKA rate was 34/235 (14.2%). 63/130 survivor TAs and 66/140 fatality TAs merited analysis as p-TKAs. Detailed pathoanatomy was only available for fatality p-TKAs, for whom definitive TKA would have been proximal to the zone of injury (ZOI) in only 3/66 cases. Blast-mediated traumatic TKAs are significantly more common than previously reported (